This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Tuesday, 3 August 2010

Charlotte Gets Yelled at For Feeding a Patient.

Charlotte is a colleague of mine who is excellent at her job. She completed her training at University about 6 years ago. She is a wonderful bedside registered nurse. She really stays on top of things and will work a 14 hour day without a break to do her best to ensure that the patients all receive their treatments and orders.

Like the rest of the RN's on the duty roster Charlotte often finds herself as the lone RN for 19 patients when she is on shift. She may have one or two apprentices to help.

Just mixing preparing and administering all of the drugs due at 8AM takes until way past lunch time when you are the lone Nurse for 19 patients.

Not only is medication administration complicated and time consuming but the lone RN will be constantly interrupted by doctors, relatives, patients, pharmacy, social services, path lab etc etc during her attempts to get her patients their first lot of drugs for the day along with a basic nursing assessment. There is no break, no let up from these interruptions.

The apprentices can neither continue with the drugs or deal with the interruptions. Many medics will show up during this time and demand that the Nurse abandon her patients to follow them around on a doctors round for an hour. The doctors don't care if patients don't get their ordered treatments or get cared for by an RN. They just like to monopolise the Nurse's time for the sheer fun of it. It takes until lunchtime for Charlotte to see each patient once and administer the drugs due at 8AM. And that is if you keep it to two minutes with each patient and then run off.

On Tuesday morning Charlotte was receiving handover from the Night Nurse. 11 out of 19 of Charlotte's patient's that day were going to be unable to feed themselves. Charlotte hauled ass that morning. She took short cuts with the drugs and ignored the phone calls from families. This was the only way she would get to a point where she could obtain the ability to feed all of her patients at lunchtime.

Noon rolls around. Both apprentices are off the ward escorting patients to diagnostic tests leaving Charlotte trying to feed 11 people by herself simultanously while handling everything else that is going on for those 19 people. She was grateful that no one was really poorly at that time and that the high priority things (blood transfusions, life saving drips that need to be put together and administered) were under control by noon.

She happily commenced a serious and whole hearted attempt to feed her 11 patients. She started with the first two patients who were next to eachother and tried to feed them at the same time while telling the patient across the bay that she would be there to help as soon as she could.

Enter Doctor Hellboy. He has been told repeatedly not to show up at lunch time to do his rounds so that the Nurses can feed the patients. When a doctor arrives to do rounds he pulls the Nurse away from whatever she is doing for a good hour and a half. But Doctor Penisbreath has a lot of patients to see and not a lot of time and it is very convienant for him to show up for rounds at lunch.

But he shows up at lunchtime anyway. He doesn't care if patients get malnourished as long as they are not his patients. He walked up to Charlotte as she was feeding her first two patients, snapped his fingers at her and announced " I am here for my rounds, come on now" and he walked away expecting Charlotte to follow him. She did not. She continued feeding her patients. He went nuts on her. Absolutely nuts.

"How dare you refuse my ward round blah blah blah how can you know what the plan is with the patients if you don't attend the ward round blah blah blah".

Charlotte held her ground and was able to get most of her patients fed.

The funny thing about this particular consultant is that he has been overheard telling the complaining family of a malnourished patient "These Nurses today cannot be bothered feeding patients, they went to university you know".

What a cock eh?

Same guy declined to give his support to our ward sister when she made a case for getting extra RN's employed so we had enough to feed the patients and attend ward rounds. Therefore we could know the "plan" with the patients and get them fed as well. My ward sister was not only shot down on that request but the medical manager, chief nurse etc laughed in her face and told her she was "exagerrating the ward conditions". None of these people have been on a ward in over 20 years.

I wouldn't bother posting this if it was a one off but the consultants are pretty much on my shit list this week for these same kinds of things. And the next few posts will reflect that.

32 comments:

Sounds like a right git. Are there no senior nurse managers that are supportive? I'm sure you have tried this already but our MAU finally started to put up a screen with the picture of the directorate manager on it and the slogan about taking protected mealtimes seriously. They then blocked the door for an hour and refused to let anyone onto the unit withour prior arrangement ( ie ED admissions). Consultants hated it but thanks to the photo they started to direct their anger at the right person...low and behold MAU were allowed to hire a few more HCAs to help with the feeding. Our Stroke unit now has a little army of helpers that work a few hours a day and their SOLE job is to feed patients...nutrition supporters I think they are called.

No Dino we are not getting any back up with this at all and their is no way they will hire nutrition helpers. Nutrition helpers will cause people to think that Nurse's don't want to "bother" with feeding anyway.

Little does the public realise that there is one qualified Nurse on the ward at mealtime (thanks to asshole managers) and the fucking doctors are monopolising her time and getting aggressive if she doesn't play ball.

Fairy, as Anne says, surgeons are worse, but I bank in theatres inbetween my placements and theyre completely different in their own habitat. The consultants and regs are ok, its the more junior ones who seem to develop god complexes even though theyre not qualified surgeons. They soon get slapped down by the nursing staff in theatre though.

Good for Charlotte - now she needs to send an incident report of inappropriate physician behavior to administration. BTW start wearing a tabard with "I AM THE ONLY NURSE ON THIS WARD" on it in big black letters...

I've been the patient needing feeding, still able to eat orally (just) but must go slowly, liquids thickened, solids mashed. I don't want to use my PEG for nutrition yet - although it's incredibly valuable for fluids and meds - but after a few days of watching your plate of food cool and congeal, occasionally actually having it removed untouched after the statutory 20 minutes... well, pass the Fortisip, I give up. It's depressing.

Nurses couldn't believe their eyes when a registrar friend dropped in to say hello and ended up staying and feeding me - I don't think that ward had ever seen such a thing.

Oh they do snap their fingers. It sounds really cliche but a few of them do it. They don't care what that lone Nurse is in the middle of, they don't care what is going on with her patients. They show up for rounds (we have no idea when they are coming so we cannot plan for it) and expect the Nurse to immediately drop what she is doing to follow them about.

Ambulance transport crews, social workers,porters, psychiatrists visitors,crisis team workers, managers, etc do the exact same thing to the Nurse at mealtime.

Everyone thinks that the Nurse exists to service them and that is why the Nurse never gets an uninterrupted moment in her day to do her job.

Ambulance crews are the worst. The worst. They show up and expect a red carpet to be rolled out for them so that they can keep to their schedule. Must be nice to only have to deal with one patient at a time. And they don't give a shit about the fact that the Nurse they are dumping on has 20 patients.

We would have a list of 20 patients to go to theatre. First person on the list would be the first one to go. Last person on this list would be the last one to go. Supposedly.

We would ring first thing in the morning and the theatres would assure is that the list was stable.

Next thing you know ( 2 minutes later)the porter shows up for patient number 11 on the list and demands to know why he isn't ready. And pulls the nurse and hca away from feeding the other patients to sort the guy out for theatre.

So we would just get everyone ready at 0900.

Once they came first thing in the morning for number 15 on the list. I didn't see them take him because I was hanging blood on a bleeder. I didn't even know that the guy had been taken to theatre until the anaestatist rang the ward screaming and hollering and wanting to know why patient hadn't had the medication that was prescribed to be given "just as he is leaving the ward for the theatre". The words in quotes are how the order was written.

If we don't know when they are going and cannot stand by their bedside all the time and theatres change the order on the list before telling us how will we actually know when they are going to theatre.

But seriously. Don't get me started about ambulance transport crews and mealtime. Motherfuckers all of them.

Also getting tired of 15 year old kitchen assistant asking me why the menus for tomorrow have not been filled in by 10am.

Me: "Sorry, I'm putting up blood on GI bleed. Be a pal and please ask the patients what they want as you are collecting them in. Why don't you ask the ward clerk to get off ebay for 5 minutes and help you?"

One of my colleagues says that if a person is backward they get a job in the hospital kitchen.

I have had to ring the kitchen at mealtime because they haven't sent up enough food.

"Well you will just have to come down ere and get it" says the kitchen worker.

But I am giving drugs that are already late, getting an admission and have a patient who just came back from theatre with a blood pressure of 55/30. I am trying to help feed patients and there is a family here who are burning holes into the back of my head because they want me to meet with them for an hour to discuss their mother's condition. And I am the only Nurse up here. I cannot come down to the kitchen.

"Well we are busy here in the kitchen too. If you want your patients to have food you'll just have to come and get it"

I wanted to say I beg your pardon but what the hell is stressful about working in the kitchen?

Your colleague is right Anne. They are either backward or foreign with no basic grasp of the English language.

One of the kitchen staff complained the other week to the matron that we do not take patient nutrition seriously, because we do not leap to the meal trolley with our green pinnies on the minute the bell is rung for protective mealtime.

I take patient nutrition as seriously as the next nurse and if I am not handing out meal trays or feeding patients it is for a damn good reason i.e.

1) Trying to get up gelofusine on hypotensive patient.

2) Obtaining an ECG and vitals on patient with crushing chest pain and a cardiac history.

3) Attempting to inform docs that patient's pedal pulses are absent and their leg is now cold and turning blue.

I would argue that not taking patient nutrition seriously is wheeling the food trolley back to the kitchen and throwing food into bin, when you are fully aware that the nursing staff have not managed to get around to all 30 patients!

You have a bell for protected mealtimes? WTF? We have the insulting red trays to let us know who needs "assistance" with feeding on the wards. In ICU we have no actual housekeeper so everyday if we do have patients who can eat we have to phone the kitchens and try and book some meals. They get no choice as we seem to get whats left over. Joy. I really wish that Cameroon or one of his chronies would pick a random medical ward and turn up unannounced. Theh they might see what working in the NHS is really like....

Steady on old Girl! Even in Little Harley Street I don't expect a nurse on the round. On my NHS round I just keep to the agreed time, and toast the F2 if he doesn't know the patient backwards including the nursing details as to fluid balance, nutrition, domestic circumstances etc. If he doesn't know then he will by the following round. I always make sure that the ward nurses are their MSF delegates. Keeps a sweet learning atmosphere all round.

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In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.